Marcus has come for a follow-up appointment at the SBHC. He reported several anxiety symptoms during his comprehensive risk assessment, and screened positively for panic attacks during the Diagnostic Predictive Scales. Marcus indicates that the panic attacks are triggered by a fear of being called on in class. He experiences symptoms of panic (heart palpitations, nervousness, sweating, etc) on the way to school, while sitting in class, and even just thinking about being in class.

4Panic Disorder Diagnostic Criteria

I. Recurrent, Unexpected Panic Attacks

Criteria for Panic Attack A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes

Palpitations, pounding heart, or accelerated heart rate

Sweating

Trembling or shaking

Sensations of shortness of breath or smothering

Feeling of choking

Chest pain or discomfort

Nausea or abdominal distress

Feeling dizzy, unsteady, lightheaded, or faint

Derealization (feelings of unreality) or depersonalization (being detached from oneself)

Fear of losing control or going crazy

Fear of dying

Paresthesias (numbness or tingling sensations)

Chills or hot flushes

5Panic Disorder Diagnostic Criteria

II. At least one of the attacks has been followed by 1 month (or more) of one (or more) of the following

Persistent concern about having additional attacks

Worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy")

A significant change in behavior related to the attacks

6What Type of Anxiety?

Philip was referred to the SBHC by his mother, because she has become increasingly concerned by his fears of going outside. Upon interview, Philip reveals that after being attacked by a neighborhood dog a few years ago, he has developed a fear of dogs. His fear is getting worse, and he is beginning to limit his outdoor activities. He reports getting nervous even when seeing dogs on television, even though he knows they cannot hurt him.

7(No Transcript) 8Specific Phobias

Marked and persistent fear of a specific object or situation with exposure causing an immediate anxiety response that is excessive or unreasonable

In children, anxiety may be expressed as crying, tantrums, freezing, or clinging.

Adults recognize that their fear is excessive. Children may not.

Causes significant interference in life, or significant distress.

Under 18 years of age symptoms must be gt 6 months

9Specific Phobias

Animal phobias most common childhood phobia.

Also frequently afraid of the dark and imaginary creatures

In older children, fears are more focused on health, social and school problems

10What Type of Anxiety?

Sally is brought to the SBHC by her parents, who are worried about her poor attendance in school. Sally has had some difficulty leaving her parents for the past several years, but her concerns have grown increasingly more intense. She reports having fears that if she goes to school, her parents will abandon her or something very bad might happen to them. She sometimes has dreams that they have died, and she wakes up in a panic. Sally has come to the SBHC several times in the past few months complaining of headaches and stomachaches, requesting that she be sent home.

11Separation Anxiety Disorder

Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following

Recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated

Persistent and excessive worry about losing, or about possible harm befalling, major attachment figures

Persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)

Persistent reluctance or refusal to go to school or elsewhere because of fear of separation

12Separation Anxiety Disorder

Persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings

Persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home

Repeated nightmares involving the theme of separation

Repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated

13Separation Anxiety Disorder

Duration of at least 4 weeks

Causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning

14What Type of Anxiety?

James walks into the SBHC for an appointment. He reports having great difficulty concentrating in his classes because of his increased worrying. He cannot pinpoint his worries Rather, he reports being nervous about many things in his life, including his relationships with peers, his grades, and even his performance in basketball. His worries are beginning to impact his sleep, and he is finding himself becoming more irritable than usual.

15Generalized Anxiety Disorder

Excessive anxiety worry for at least 6 months, more days than not

Worry about performance at school, sports, etc.

DSM IV criteria less stringent for children (Need only one criteria instead of three of six)

Shelleys teacher brings her down to the SBHC because he is concerned that her grades have been declining, and he has noticed that she has not been completing her homework. Shelley reports that she is being plagued by distressing thoughts of doing bad things, including hurting herself and others. In order to get rid of the thoughts, Shelley often has to engage in intricate routines, including counting to 1000 and backwards, and touching her desk at home in specific patterns. Although these routines decrease her anxiety, they are causing her to skip homework assignments and even lose sleep.

17Obsessive Compulsive Disorder

Presence of Obsessions (thoughts) and/or Compulsions (behaviors)

Although adults may have insight, kids may not

Interferes with life or causes distress

One third to one half of all adult patients report onset in childhood or adolescence

18What Type of Anxiety?

Ginny comes to the SBHC for a sports physical. During her risk assessment, she reveals that her parents have a history of domestic violence, and that she witnessed her father attack her mother on several occasions. In the past few months, Ginny has been having nightmares about the abuse, and finds herself having flashbacks even during class. Ginny has been avoiding certain rooms in her house that remind her of the incidents. She also reports having difficult sleeping and concentrating in class.

19Post-Traumatic Stress Disorder (PTSD)

The person has been exposed to a traumatic event in which both of the following were present

The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

The person's response involved intense fear, helplessness, or horror. (Note In children, this may be expressed instead by disorganized or agitated behavior.)

20Persistent Re-Experiencing of Event (1)

Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. (Note In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.)

Recurrent distressing dreams of the event. (Note In children, there may be frightening dreams without recognizable content.)

Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). (Note In young children, trauma-specific reenactment may occur.)

Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

21Avoidance and Numbing (3)

Efforts to avoid thoughts, feelings, or conversations associated with the trauma

Efforts to avoid activities, places, or people that arouse recollections of the trauma

Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

22Increased Arousal (2)

Difficulty falling or staying asleep

Irritability or outbursts of anger

Difficulty concentrating

Hypervigilance

Exaggerated startle response

23Post-Traumatic Stress Disorder (PTSD)

At least one month duration.

Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

Note Many students with PTSD meet criteria for another Axis I Disorder (e.g., major depression, Panic Disorder) both should be diagnosed

24Anxiety Disorder NOS

Disorders with anxiety symptoms BUT do not meet criteria for any specific Anxiety Disorder, Adjustment Disorder with Anxiety, or Adjustment Disorder with Mixed Anxiety and Depressed Mood

Example mixed anxiety-depressive disorder

Also used in situations in which clinician has concluded that an anxiety disorder is present, but is unable to determine whether it is primary, due to medical condition, or substance induced

25Depressive Disorders

Major Depressive Disorder

Dysthymic Disorder

26Depression

Epidemiology

2.5 of children, up to 5 of adolescents

Prepubertal-11/MF adolescence-41/FM

Average length of untreated MDD-7.2 months

Recurrence rates-40 within 2 years

Genetics

Most important risk factor for the development of depressive illness is having at least one affectively ill parent

27What Type of Depression?

Tonya has come for an initial appointment to the SBHC. During the risk assessment, Tonya reports a number of depressive symptoms, including suicidal ideation. Tonya seems to display a lot of negative thinking and cognitive distortions. For example, she believes that nobody likes her and that s/he will never be successful in school. Her math teacher often compliments her work, but Tonya dismisses the teachers comments as him just trying to be nice. Tonya has good grades in all classes except for one, yet she only acknowledges her below average Chemistry grade. Tonya has felt extremely sad for about three weeks, which is a contrast from her usually happy disposition.

28Major Depressive Disorder

Major Depressive Episode

Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning. At least one symptom is either (1) depressed mood or (2) loss of interest or pleasure.

Depressed mood most of the day, nearly every day, as indicated by subjective report or based on the observations of others. In children and adolescents, this is often presented as irritability.

Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day

Significant weight loss when not dieting or weight gain (change of more than 5 of body weight in a month), or decrease or increase in appetite nearly every day

Insomnia or hypersomnia nearly every day

Psychomotor agitation or retardation nearly every day (observable by others)

Fatigue or loss of energy nearly every day

Feelings of worthlessness or inappropriate guilt nearly every day

Diminished ability to think, concentrate, make a decision nearly every day

Recurrent thoughts of death, recurrent suicidal ideation with or without a specific plan, or an actual suicide attempt

29Major Depressive Disorder

Symptoms cause clinically significant distress or impairment in social or academic functioning

Symptoms are not due to the direct physiological effects of a substance (drugs or medication) or a general medical condition

Although there is a different diagnostic category for individuals who suffer from Bereavement, many of the symptoms are the same and counseling techniques may overlap.

Maria comes for a follow-up appointment to the SBHC. Her risk assessment showed that she has felt sad or blue for at least two weeks. Upon further inquiry, Maria reports that she generally feels sad, and finds little enjoyment in activities. She reports having felt this way for several years. In fact, she cant recall a time when she didnt feel mostly down. She denies suicidal ideation, and is doing pretty well in school. She is not very social, but does have a few friends.

37Dysthymic Disorder

Major difference between a diagnosis of Major Depressive Disorder and Dysthymia is the intensity of the feelings of depression and the duration of symptoms.

Dysthymia is an overarching feeling of depression most of the day, more days than not, that does not meet criteria for a Major Depressive Episode.

Impairs functioning and lasts for at least one year in children and adolescents, two in adults.

38Depressive Disorder NOS

Disorders with depressive symptoms BUT do not meet criteria for Major Depressive Disorder, Dysthymic Disorder, Adjustment Disorder with Depressed Mood, or Adjustment Disorder with Mixed Anxiety and Depressed Mood

Also used in situations in which clinician has concluded that a depressive disorder is present, but is unable to determine whether it is primary, due to medical condition, or substance induced

39Disruptive Disorders In Children

Attention Deficit Hyperactivity Disorder

Oppositional Defiant Disorder

Conduct Disorder

Disruptive Behavior Disorder NOS

40What Type of Disruptive Behavior Disorder?

Joseph was referred to the main office by his teacher for disrupting her class. Josephs teacher reported that she cannot manage him in class because he is constantly out of his seat and will not concentrate on work. He has a hard time completing tasks, and is very disorganized. He talks back to her occasionally when frustrated, but is not frequently defiant. His peers are getting tired of him constantly interrupting them, and he is losing friends quickly.

41Attention Deficit Hyperactivity Disorder

Symptoms for at least six months to a degree that it is maladaptive and INCONSISTENT with developmental level

Some symptoms present prior to age 7 years

Two or more settings

42Attention Deficit Hyperactivity Disorder

Inattention

Poor organization

Does not seem to listen when spoken to

Loses objects

Easily distracted

Forgetful in daily activities

Hyperactivity/Impulsivity

Fidget

Leaves seat often

Runs or climbs excessively

Always on the go

Talks excessively

Blurts out answers

Cant wait turn, interrupts others

43Attention Deficit Hyperactivity Disorder

Attention deficit disorder can occur WITH and WITHOUT hyperactivity

Hyperactivity is more common in boys than girls

44Attention Deficit Hyperactivity Disorder

ADHD can be a lifetime disorder with 30-50 having symptoms as adults

Learning Disabilities are frequently seen in children with ADHD

Behavior in a providers office does NOT always reflect the situation at home or in school

45What Type of Disruptive Behavior Disorder?

The principal of your school has called you to a meeting with Jonathons parents and his teachers, all of whom complain that Jonathon has been acting out for over a year, and refuses to listen to their direction. He is constantly arguing with all authority figures, and will not take responsibility for his actions. Jonathons teacher and mother say that he is always angry, and that he lashes out at everyone around him. He has been breaking more rules at home and in school. He has not been drinking alcohol or using drugs, not has he broken the law up until this point, but his parents are worried that his behaviors are going to grow steadily worse.

46Oppositional Defiant Disorder

A pattern of negativistic, hostile and defiant behavior lasting greater than 6 months of which you have 4 or more of the following

Loses temper

Argues with adults

Actively defies or refuses to comply with rules

Often deliberately annoys people

Blames others for his/her mistakes

Often touchy or easily annoyed with others

Often angry and resentful

Often spiteful or vindictive

47Oppositional Defiant Disorder(ODD)

Prevalence-3-10

Male to female -2-31

Outcome-in one study, 44 of 7-12 year old boys with ODD developed into CD

Evaluation-Look for comorbid ADHD, depression, anxiety LD/MR

48What Type of Disruptive Behavior Disorder?

Matthew was referred to the social worker at the SBHC because he has been going down the wrong path for several years, according to his mother. Matthews negative behaviors began before puberty, when he started hanging out with negative peers. Matthews mother has caught him hurting their family pet as well as other animals, and he was recently arrested for vandalizing school property. He has been getting into frequent fights at school without apparent instigation. Matthews mother also realized that he had stolen from her when she noticed 50 missing from her purse and found it in his pocket.

49Conduct Disorder (CD)

Aggression toward people or animals

Deceitfulness or Theft

Serious violation of rules

Destruction of property

50Conduct Disorder (CD)

Prevalence-1.5-3.4

Boys greatly outnumber girls (3-51)

Comorbid ADHD in 50, common to have LD

Course-remits by adulthood in 2/3. Others become Antisocial Personality Disorder

Animal studies show that early exposure to alcohol results in longer term problems such as cognitive and behavioral problems

57Dependence vs. Abuse

Dependence A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period

Tolerance, as defined by either of the following

A need for markedly increased amounts of the substance to achieve intoxication or desired effect or

Markedly diminished effect with continued use of the same amount of the substance

Withdrawal, as manifested by either of the following

The characteristic withdrawal syndrome for the substance or

The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

The substance is often taken in larger amounts or over a longer period than was intended.

58Dependence vs. Abuse

There is a persistent desire or unsuccessful efforts to cut down or control substance use.

A great deal of time is spent n activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects

Important social, occupational, or recreational activities are given up or reduced because of substance use.

The substance use is continued despite knowledge of having a persistent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption).

59Dependence vs. Abuse

Abuse A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring at any time in the same 12-month period

Recurrent substance use resulting in a failure to fulfill major role obligations at wok, school, or home (e.g., repeated absences or poor work performance related to substance use substance-related absences, suspensions, or expulsions from school neglect of children or household

Recurrent substance use in situations in which it is physically hazardous (e.g. driving an automobile or operating a machine when impaired by substance use)

Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequence of intoxication, physical fights)

The symptoms have never been met the criteria for Substance Dependence for this class of substance.

60Dependence vs. Abuse?

Martina was referred to the substance abuse counselor because her teacher thinks she has been high during class. Martina reported to the counselor that she has been drinking alcohol and smoking marijuana for the past couple of years, and that she is having to drink and smoke more to feel the same effects that she used to. She notices that when she does not drink, she has trouble sleeping at night. Martina reports trying to stop drinking and smoking in the past, but she never succeeded. She has recently been cutting classes to purchase alcohol and drugs.

61DEPENDENCE 62Dependence vs. Abuse?

During his sports physical at the SBHC, Samuel reported that he has drank alcohol in the past several months. He indicated that he only drinks on the weekend, and that he usually drinks the same amount (a few beers) each weekend. His family and his girlfriend have complained to him that his drinking is causing problems in their relationships, and have asked him to stop. Over the past summer, Samuel was arrested for drinking while driving. He also said that he has been late to work a few mornings because he had stayed out late drinking.

63ABUSE

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